Purpose: Plate and cable alone constructs to treat periprosthetic fractures around a well-fixed femoral stem in total hip replacements, have been reported with high failure rates. The aim of this study was to evaluate the results of our surgical treatment algorithm to reliably use lateral plate and cable constructs in these fractures.

Method: One hundred and six periprosthetic fractures in 102 patients were treated between 1996 and 2006. Forty-five fractures were pre-operatively assessed as Vancouver type B1 fractures. The joint was always dislocated and stability of the implant was meticulously evaluated. This led to the identification of nine (20%) unstable stems leaving 36 fractures to be real B1-type fractures. The fracture was considered to be suitable for lateral plate and cable alone fixation if the medial cortex was not comminuted and an anatomical reduction of the medial cortex could be achieved. Twenty-nine B1- and 5 C-type fractures had been treated with a single lateral plate and cable construct. The mean length of follow-up was 43.2 months. The paired Student’s T-test with a confidence interval of 95% and a significant p-value of p< 0.05 was used to compare the pre- and postoperative UCLA hip scores.

Results: Four (12%) patients died within one month from surgery leaving 30 patients for follow-up. Twenty-nine fractures united at a mean of 6.4 months. One B1-type construct failed due to inappropriate proximal fixation. Two fractures united uneventfully with a mean of 8° of varus alignment of the proximal fragment. One patient with a C-type fracture sustained a fracture distal to the tip of the plate. There were three plate infections (8.8%). There was no significant difference between the pre- and post-operative UCLA hip scores (25 versus 23 resp.).

Conclusion: These fractures represent a difficult problem with a high complication rate of 30%. The presented treatment algorithm contributed significantly to the 97% union rate with plate and cable alone constructs that was comparable to the union rates achieved with combined plate and strut graft fixation.

Purpose: We reviewed all isolated tibial shaft fractures treated by operative means, with focus on prolonged healing and infection. Design; Retrospective Case Control Study; level of evidence; Prognostic level III.

Methods: Patients: 821 isolated tibial shaft fractures, with a drop-out of 5.6% Open fractures: 400 (grade I & II 280, grade IIIa,b,c 120) Type A,B fractures: 597 Type C fractures: 224 Skeletal Fixation Modes: Ex;Fix (unilateral-one plane): 192, UTN(Synthes): 337, Plate(LCDCP): 129, RTN(Synthes): 163

Outcome measurements: Union time, requirement for secondary treatment, and development of deep infection.

Results: Infections: 94 (11,4%), Closed # which became infected: 21 (5%) Open # which became infected: 73 (18%) Ex.Fix: 56 (29%) Plate: 15 (12%) UTN: 16 (5%) RTN: 7 (5%) In a multiple logistic regression analysis, only Soft tissue damage had a statistical significant interference with the outcome infection (point estimate 0.117, 95% CI 0.053–0.262) Prolonged healing: 285 (34%)? Delayed union 191 ? Non-union 94 Closed fractures which develop a delayed healing: 56 (13%) Open fractures which develop a delayed healing: 135 (34%) Closed fractures which develop a non-union: 20 (5%) Open fractures which develop a non-union: 74 (19%) In a multiple logistic regression analysis, infection & fracture type had a statistical significant interference with the outcome prolonged healing.

Conclusions: The use of an unilateral external fixator as a definitive treatment for tibial fractures is obsolete. For a contaminated tibial fracture the use of the UTN diminish the risk of infection. Looking for the healing time, UTN & Ex.Fix. are associated with a significant prolonged bone healing time.

Aim: presentation of a new lengthening device which is reliable and overcomes the problems seen with the classical Ilizarov frame, based on the principle of fluid mechanics.

Methods: we followed ten cases until bone healing. After corticotomy, the telescoping nail is brought into the femur or tibia like a normal IM nail. Diameter for the femoral nail 13 mm, 12mm for the tibia nail. In the proximal sector of the nail, the sterile arachid oil presses the plunger of the hydraulic actuator (pressure cell) out of the piston. It pushes against the distal nail which is locked in the distal femur with two screws. In all but one case, lengthening was done because of post-traumatic shorthening. In one femur with a defect of 10 cm a bone transport was performed using this system to fill the gap.

The pressure in the nail was increased with an external syringe-pump, attached two times daily via a quick coupling (swage lock) mechanism to the inlet port of the nail (60 Bar for the femur and 40 Bar for the tibia). Lengthening at a rate of 1.8 mm day was possible with remarkable comfort for the patient. The silver coated inlet port (tube of 2mm) gave no skin reaction in nine cases. In one femur there was slight drainage of fluid which stopped spontaneously after two weeks. While lengthening, patients were allowed to walk with partial weight bearing.

After lengthening, the oil was released and the inlet port cut off underneath the skin.

Results: all cases could be brought up to length in the desired time frame. Additional surgery was necessary in two cases to enhance bone healing (one autologous bone graft, one bone marrow injection). No implant failure or other undesired side effects were noticed with this method.

Conclusion: preliminary good results were achieved with this new apparatus, which seems to give reproducible results with less burden to the patient. Lengthening can be achieved much faster than with the classical distraction method of Ilizarov.

Aims: to evaluate the efþcacy of this technique in 46 tibias and 22 femurs with a delayed bone healing (> 6 months) with a minimum follow-up of one year after injection. Methods: Forty-þve injections were performed in a one-day clinic. At least 300 ml autologeous bone marrow is aspirated from the iliac crest using multiple aspiration sites. Through isopyknic centrifugation the mixture of bone marrow and phosphateÐbuffered saline was layered over undiluted Ficoll-Paque. Centrifugation was done for 35 min. at 400 times gravity. An average of 52 cc of mainly myeloid cells were obtained with a nucleated recovery rate of average 62% (27–90%). In 21 cases additional surgery was performed at the moment of bone marrow grafting. Eleven times an implant exchange, seven dynamisations and 3 additional bonegrafting. The bone marrow grafting was performed through cannulated screws seated in the medullary cavity below and above the fracture site. Results: we encounter one postoperative irritation of the pes anserinus tendons due to inþltration. Despite the fact that we aspirated an average of 340 cc of bone marrow no adverse reaction was seen from this nor from the sometimes forceful injection of 50 cc concentrated bone marrow. In eight cases no bone healing occurred. In þve cases, probably due to a lack of stability and implant failure. Conclusions: the use of concentrated bone marrow injected in the medullary cavity near the fracture site is cost effective and seems to give favorable results.

Fractures of the shaft of the humerus are usually easy to treat, irrespective of the personality of the fracture.

The blood supply is abundant that union is rapid. There is no tendency to over-riding; on the contrary, the only danger is that the fragments may be allowed to distract by the weight of the limb and cause delayed union. The middle third is the most vulnerable in relation to delayed or non-union. This is because the main nutrient artery enters the bone very constantly at the junction of the middle and lower thirds or in the lower part of the middle third. The radial nerve is another structure at risk from fractures or operations on the humerus. It does not travel along the spiral groove of the humerus next to the bone as is commonly described; instead along most of its course it is separated from the humerus by a variable layer of muscle, and lies close to the inferior lip of the spiral groove.

In general treatment of the fractured shaft of the humerus is not usually difficult. The fractured ends can be readily aligned with the patient sitting, when the weight of the forearm on the distal fragment will usually achieve an acceptable position. Support of the wrist a collar and cuff or narrow sling, allowing the elbow to lie free and unsupported may be all that is required. In the early stages when there is considerable pain a well padded plaster of Paris U-slab passing from the region of the acromion down to the olecranon and up the inner side of the arm to the axilla and bandaged in place is very effective in relieving discomfort. After two weeks the collar and cuff bandage can be replaced by a functional orthosis type Sarmiento for another four to six weeks. A “ hanging cast” popularized by Caldwell is no longer recommended because it may distract the fracture and produce delayed union.